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Aim: Active perinatal care (APC) increases the survival of extremely preterm (EPT) infants, but may increase the rate of disabilities. We examined neurodevelopmental outcomes in adolescents aged 10-15 years who were born EPT and received APC in two Swedish tertiary care centres.Methods: Cognitive function was assessed using the Wechsler Intelligence Scale for Children, and neurosensory impairments were assessed by reviewing the case records and a standard parent health questionnaire. The outcomes were compared to term-born controls.Results: We assessed 132 EPT adolescents and 103 controls. The rates of cerebral palsy, moderate to severe visual impairment and moderate to severe hearing impairment were 9%, 4% and 6%, respectively, for the EPT children and zero for the controls. Serious cognitive impairment was present in 31% of the EPT adolescents and 5% of the controls. Combining impairments across domains showed that 34% of EPT adolescents had moderate and severe disabilities compared with 5% of the controls. Impairments were more common at 23-24 weeks of gestational age (43%) than at 25 weeks (28.4%).Conclusion: Two-thirds (66%) of adolescents born EPT who received APC had mild or no disabilities. Our results are relevant for healthcare providers and clinicians counselling families. [ABSTRACT FROM AUTHOR]

Aims: To assess the cognitive and behavioral aspects of executive functioning (EF) and learning skills in extremely preterm (EPT) children compared with term control children aged 10 to 15 years. Methods: A total of 132 of 134 (98% of all eligible survivors) EPT children born at the 2 Swedish regional tertiary care centers from 1992 to 1998 (mean age = 12 years, mean birth weight = 718 g, and mean gestational age = 24.4 weeks) and 103 matched term controls were assessed. General intelligence was assessed using the Wechsler Intelligence Scale for Children (WISC-III-R), and cognitive aspects of EF were analyzed using EF-sensitive subscales of the WISC-III-R and Tower test of the Delis-Kaplan Executive Function Scale (D-KEFS). Behaviors related to EF and learning skills were assessed using the Five to Fifteen questionnaire, which is a validated parent and teacher instrument. Academic performance in school was assessed by teachers’ responses on Achenbach’s Teachers Report Form. Analyses performed included multivariate analyses of covariance (ANCOVA and MANCOVA) and logistic regression analyses. Results: The EPT children displayed significant deficits in cognitive aspects of EF compared with the controls, exhibiting decreases on the order of 0.9 SD to 1.2 SD for tasks of verbal conceptual reasoning, verbal and non-verbal working memory, processing speed and planning ability (P <0.001 for all). After excluding the children with major neurosensory impairment (NSI) or a Full Scale intelligence quotient (FSIQ) of < 70, significant differences were observed on all tests. Compared with controls, parents and teachers of EPT children reported significantly more EF-related behavioral problems. MANCOVA of teacher-reported learning skills in children with FSIQ >70 and without major NSI revealed no interactions, but significant main effects were observed for the behavioral composite executive function score, group status (EPT vs control) and FSIQ, for which all effect sizes were medium to large. The corresponding findings of MANCOVA of the parent-reported learning skills were very similar. According to the teachers’ ratings, the EPT children were less well adjusted to the school environment. Conclusion: EPT children born in the 1990s who received active perinatal care are at an increased risk of executive dysfunction, even after excluding children with significant neurodevelopmental disabilities. Even mild to moderate executive dysfunctions has a significant impact on learning skills. These findings suggest the need for timely interventions that address specific cognitive vulnerabilities and executive dysfunctions. [ABSTRACT FROM AUTHOR]

PURPOSE: Swedish hospitals apply various regimens for preterm infants' nutrition in connection with their mother's establishment of breastfeeding. Milk intake is assessed either by test weighing before and after breastfeeding or by observing the infant's suckling behavior (ie, clinical indices). These differing policies may lead to differences in infants' feeding progress. The purpose of this study was to compare effects on breastfeeding and weight gain of preterm infants, depending on whether the volume of breast milk intake when suckled in the hospital was estimated by 'clinical indices' or determined by test weighing. SUBJECTS: Sixty-four infants treated at a unit applying test weighing were compared wtih 59 infants treated at a unit assessing milk intake by 'clinical indices.' DESIGN AND METHODS: A retrospective, descriptive, and comparative design was used to explore the consequences of different nutrition regimens. Data were obtained from a review of hospital medical records. PRINCIPAL RESULTS: The infants treated at the hospital where test weighing was practiced attained exclusive breastfeeding at an earlier postmenstrual age (PMA) and were also discharged at an earlier PMA. However, the 2 study units were alike regarding the proportion of infants attaining exclusive breastfeeding, the postnatal age when this occurred, and the weight pattern in hospital. CONCLUSION: To establish breastfeeding in preterm infants, test weighing before and after breastfeeding and gradual reduction of supplementation are both applicable regimens. Mothers can be encouraged to choose either of them, although test weighing may help infants attain exclusive breastfeeding at an earlier PMA. [ABSTRACT FROM AUTHOR]

The effect of protein enrichment of mother's milk on growth of low birthweight infants needs further exploration in order to optimize feeding strategies. The aim of this study was to describe feeding and growth of infants weighing <1,900 g at birth, up to a corrected age of 18 months, with or without protein-enriched breastmilk. A retrospective, descriptive, non-experimental design was used to describe the growth of 52 low birthweight infants. Data on their growth and feeding were collected from medical records at hospitals and child health care clinics. Despite more severe morbidity, the infants given protein-enriched milk showed similar growth as the other study infants. Standard deviation score for length at birth correlated positively with delta standard deviation score for length, from discharge to 12 and from discharge to 18 months corrected age. Duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. At discharge a smaller proportion of singletons fed with protein enriched milk were breastfed `fully'. Infants who established breastfeeding at an early post-menstrual age were born with more optimal weight standard deviation score and had a better weight gain after discharge. We conclude that protein-enriched breast milk enables low birthweight infants requiring especially intensive care to attain growth at discharge comparable to that of healthier infants not given enriched milk. Low standard deviation score for length at birth may predict poor growth after discharge. However duration of 'full' breastfeeding had a significant impact on subsequent improvement in SDS for weight. Therefore it is important that mothers of LBW infants are given sufficient support of lactation and breastfeeding. [ABSTRACT FROM AUTHOR]

Unlabelled: Regional differences in stillbirth and neonatal death rates in Sweden were studied and a cause-of-death analysis was done in the 4 counties (among 24) with an increased mortality. The study is based on a computerized evaluation of infant cause of death, using a slightly modified Wigglesworth classification and a hierarchical classification (NICE: Neonatal and Intrauterine death Classification according to Etiology). Differences between the identified counties with respect to specific causes of death were demonstrated.Conclusion: There are differences between Swedish counties with respect to the risk for stillbirth or neonatal death. The NICE cause-of-death classification can be used for the routine surveillance of stillbirths and neonatal deaths in a population and can help in pinpointing weak elements in antenatal, delivery and neonatal care. [ABSTRACT FROM AUTHOR]

Unlabelled: A register-based study of the impact of obstetric and neonatal care on stillbirth and neonatal death rate was performed on all births in Sweden in 1983-1995. Each birth was assigned to a primary delivery hospital where the mother with a term singleton pregnancy was most likely to have been delivered (not possible for 25% of the deliveries), and the catchment areas of each hospital were classified according to the level of care of that hospital. Only small differences in total mortality existed between the different levels of care of the primary hospital: areas served by primary hospitals with obstetric service and resources for neonatal intensive care including continuous positive airway pressure but without facilities for ventilator treatment for prolonged periods showed a 7% excess risk of stillbirth or neonatal death.Conclusion: In areas with the lowest level of care of the primary delivery hospitals (with no or only basic neonatal care) the total mortality was not increased, indicating that the referral system works well. When the analysis was repeated for specific causes of death, more marked differences were noted, especially for death due to obstetric complications where the death risk increased with decreasing level of care of the primary delivery hospital. Even though no marked differences in total mortality were seen, a further reduction can be obtained by increasing referral for some specific conditions. [ABSTRACT FROM AUTHOR]

Background: To study specific effects of four maternal risk factors: age, parity, educational level, smoking, for specific causes of stillbirth and neonatal death according to a previously described hierarchic classification.Methods: The study is based on 9,785 stillbirths or neonatal deaths among infants born in Sweden, 1983-1995 (n=1,412,754) and identified with various Swedish health registers. Statistical analysis is performed using Mantel-Haenszel analysis.Results: Some risk factors, known from the literature, were confirmed and could be quantified. In addition, high parity was shown to increase the risk for death associated with multiple births (OR=2.49, 95% CI 2.07-3.01) and low educational level seems to be protective for such death (OR=0.75, 95% CI 0.60-0.93). If the infant is SGA, the risk for death is higher at high than at low parity (1.70, 95% CI 1.19-2.43, and 1.0, 95% CI 1.06-1.15, respectively). Maternal smoking seems to aggravate the placental abruption because the death risk in the presence of abruption increases when the mother smoked (OR = 1.74, 95% CI 45-2.08).Conclusions: The study shows that the groups of the classification system used (NICE) differ in their association with known risk factors for stillbirth and neonatal deaths and an analysis based on specific causes of death can therefore unravel risk factors hidden when total mortality is used. The computerized method of classification and the cause-of-death classification developed by us is clearly useful for such analyses which requires large materials. [ABSTRACT FROM AUTHOR]

Background: Stillbirths and neonatal deaths are often the result of a complicated chain of events. For epidemiological purposes a classification into single cause of death groups is essential. For large-scale studies, a method is needed which enables such grouping based on available register data.Methods: A cause of death classification system called NICE is presented. It is hierarchical and is aetiologically orientated. A computerized method is adapted which makes use of data in four central Swedish registries. A validation of the computer method has been made from the medical records on a 10% sample of all stillbirths and neonatally dead infants in Sweden from 1983 to 1990.Results: The specificity of the computer method is high, sensitivity is less satisfactory for some subgroups. A time trend analysis illustrates the usefulness of the classification system and shows a decline with time for two groups: placental abruption and obstetric complications.Conclusions: The NICE classification system fulfils the criteria of an aetiologically orientated classification system which can be used in a computerized environment. [ABSTRACT FROM AUTHOR]

Background: In large-scale epidemiological studies of stillbirths and neonatal deaths a method is needed to replace detailed medical record audits in order to determine the cause of death.Methods: A computer-based method is presented for determination of the cause of death in stillbirths and in neonatal deaths. It utilizes information in the Swedish medical registries. The study comprises 6044 dead infants born in Sweden from 1983-1990. For each infant the program determines 31 basic characteristics which are important in deciding the cause of death. Based on these characteristics a modified Wigglesworth's classification is used to find the cause of death. The validity of the method was checked by comparing the computer generated information with information obtained by scrutinizing medical records for a 10% representative sample (603 infants).Results: Specificity and sensitivity for each basic characteristic varied, but for the modified Wigglesworth cause of death classification the concordance was 88%. The weakest data refer to intrauterine deaths, where pertinent information was often missing in the medical registries.Conclusion: The method can be used for large-scale epidemiological studies. [ABSTRACT FROM AUTHOR]

A survey to assess the vitamin D nutritional state in 119 pregnant women at term and in their newborns was undertaken in Riyadh, Saudi Arabia. Concentrations of 25-hydroxy vitamin D (25-(OH)D) were below 4 ng/ml in 30 of 119 maternal sera, in 11 of which they were undetectable. The median concentration of 25-(OH)D was 5.7 ng/ml, which is comparable to that found in Asian vegetarian women at term in London. Fifty of 119 cord samples had undetectable 25-(OH)D, and a total of 81 samples had 25-(OH)D concentrations of less than 4 ng/ml. Despite the low 25-(OH)D concentrations cord bloods had calcium concentrations higher than those in maternal blood, while serum albumin concentration was similar in maternal and cord samples. Higher socioeconomic background of women, antenatal care, and vitamin D supplementation were associated with significantly higher concentrations of 25-(OH)D. Vitamin D supplementation, however, had no significant effect on 25-(OH)D concentration in cord samples or on the weight of the newborns. This study shows the high prevalence of marginal vitamin D nutrition in women in Saudi Arabia, which may predispose babies to rickets during infancy. In a country endowed with plentiful sunshine, the exclusion of sunshine by thick dark veils and bad housing probably contribute to this marginal state of vitamin D nutrition. [ABSTRACT FROM PUBLISHER]

Large-scale analyses of causes of neonatal deaths are usually based on death-certificate information. A new computer-based method has been introduced to define the cause of stillbirths and neonatal deaths in large amounts of material and to classify them according to two different models [Wigglesworth and Neonatal and Intrauterine death Classification according to (a)Etiology (NICE)]. The method is based on a combination of detailed information from health care registries and the death-certificate information. The present study aimed to compare these two classification models with a previously published method based solely on death certificate information [International Collaborative Effort (ICE)]. The study population comprised 2378 neonatal deaths in Sweden between 1987 and 1992. Cross-tabulation was made between the ICE classification and the other two classification models. In addition, case examples are presented in detail, exemplifying how classification errors arose. The ICE classification gives a rather low precision, notably for two important causes of death: asphyxia and immaturity. Among 328 infants dying from asphyxia according to computerized Wigglesworth classification, ICE classified 59% as asphyxia and 22% were labelled immaturity. When ICE classified the deaths as due to asphyxia, this was verified in only 50%. Among 792 infants dying from immaturity according to computerized Wigglesworth classification, 64% were classified as such by ICE. The findings cast doubts on the results of studies based exclusively on death-certificate information. Whenever possible in the analysis of neonatal deaths, death-certificate information should be supplemented with more detailed data. The computer-based method introduced here makes such analyses possible for large databases. [ABSTRACT FROM AUTHOR]

A prospective national investigation comprising 633 extremely low birthweight (ELBW) infants born alive in the 2-y period 1990-1992 with a birthweight of < or = 1000 g and gestational age of > or = 23 completed weeks was conducted regarding neurosensory outcome and growth. Three-hundred and sixty-two (98%) surviving ELBW infants were assessed at a median age of 36 months, using a specially designed protocol. At follow-up, mean height, weight and head circumference in both boys and girls were significantly lower than the reference values. The incidence of cerebral palsy was 7% among all children and 14%, 10% and 3% in children born at 23-24, 25-26 and > or = 27 gestational weeks, respectively. At least one obvious handicap was present in 14%, 9% and 3% of these three groups of children, respectively. After adjustment for gestational age, a significantly increased risk of handicap was found in children with intraventricular haemorrhage grade > or = 3 and/or periventricular leucomalacia and in children with retinopathy of prematurity stage > or = 3. The results show that more than 90% of ELBW children born at > or = 25 completed gestational weeks were without neurosensory handicap at 36 months of corrected age. In infants born at 23-24 weeks of gestation, both survival and long-term outcome were less favourable. [ABSTRACT FROM AUTHOR]

The aim was to investigate whether kangaroo care (KC) with and without nasogastric tube feeding (NG) is tolerated by sick preterm infants during the first week of life. Seventeen infants with current or resolving illness received 1 h of KC. The study patients were originally recruited for a study on the response of intestinal peptides to feeding during KC. Median gestational age was 28 wk and median birthweight 1238 g. During KC, eight infants received NG. During KC, oxygen requirements were unchanged or decreased in 15 infants and increased in 2 infants. Changes in arterial blood gases, transcutaneous pO[sub 2]/pCO[sub 2], heart rate and temperature were minimal. One episode of apnoea occurred. In conclusion, KC was well tolerated, as was NG, during KC. [ABSTRACT FROM AUTHOR]

Aim: We evaluated the increased centralisation of extremely preterm (EPT) births in Sweden in relation to the changes in mortality and morbidity., Methods: Population-based data covering Swedish live births from 22 + 0 to 26 + 6 weeks of gestation during 2004-2007 and 2014-2016 were analysed for associations between time-period, birth within (inborn) or outside (outborn) regional centres, and outcomes., Results: Among 1626 liveborn infants, 703 were born in 2004-2007 and 923 in 2014-2016. Birth outside (vs. within) regional centres was associated with a higher infant mortality even after adjustment for birth cohort, gestational age, birthweight standard deviation score and infant sex (adjusted odds ratio 2.01, 95% confidence interval 1.31-3.07, p = 0.001). The higher 1-year mortality in outborn infants was mainly due to more deaths within 24 h after birth. Outborn infants had a higher incidence of intraventricular haemorrhage grade 3-4 than inborn infants (22% vs. 14% in 2004-2007, and 22% vs. 13% in 2014-2016, both p < 0.05). While survival to 1 year without major morbidity increased in inborn infants (33%-40%, p = 0.008), it remained unchanged in outborn infants (29% vs. 30%, p = 0.88)., Conclusion: Centralisation of EPT births contributed to a lower 1-year mortality in 2014-2016 than that in 2004-2007, attributed to a decrease in deaths before 24 h among inborn infants., (© 2024 The Author(s). Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Background: Our aim was to evaluate if increased survival and new ventilation strategies were accompanied by a changed incidence of bronchopulmonary dysplasia (BPD) in Sweden over a decade., Methods: Data from two Swedish population-based studies of live-born infants with gestational age (GA) 22-26 weeks, born during 2004-2007 (n=702) and 2014-2016 (n=885), were compared for survival, any BPD, moderate BPD and severe BPD and the composite outcomes of any BPD or death and severe BPD or death at 36 weeks postmenstrual age (PMA). Ventilation strategies and interventions were analysed. Any BPD was defined as the use of supplemental oxygen or any respiratory support at 36 weeks PMA, moderate BPD as nasal cannula with <30% oxygen and severe BPD as ≥30% oxygen, continuous positive airway pressure (CPAP) or mechanical ventilation., Results: Survival to 36 weeks PMA increased from 72% to 81% (p<0.001). Total days on mechanical ventilation increased from a median of 9 to 16 days (p<0.001). High-flow nasal cannula (HFNC) was introduced between the cohorts, and days of CPAP and HFNC increased from 44 to 50 days (p<0.001). Any BPD was unchanged at 65% versus 68%. Moderate BPD increased from 37% to 47% (p=0.003), while the incidence of severe BPD decreased from 28% to 23% (p<0.046). Severe BPD or death decreased from 48% to 37% (p<0.001), while any BPD or death remained unchanged at 74% versus 75%., Conclusion: Even though an increased survival of infants born at 22-26 weeks GA was accompanied by an increased duration of invasive and non-invasive respiratory support, the incidence of any BPD remained unchanged, while severe BPD decreased in infants alive at 36 weeks PMA., Competing Interests: Conflict of interest: L. Löfberg reports support for the present manuscript from Östergötland County Council, Linköping, Sweden. They also report support for attending meetings and/or travel from Crown Princess Victoria Children's Hospital, Linköping, Sweden. T. Abrahamsson has nothing to disclose. L.J. Björklund has nothing to disclose. L. Hellström Westas reports grants from the Swedish Research Council, participation on a data safety monitoring board with the BANON (Biomarkers And Neurological Outcomes in Neonates) Advisory Board (2018–2023), leadership roles with the Swedish National Board of Health and Welfare (Scientific Advisor in Neonatology), Queen Silvia Jubilee Foundation (Research Board), Foundation Acta Paediatrica (Board member), Swedish Paediatric Association (Chair 2020–2022) and John Lind Foundation (Board member), and stock with NeoEnergy Sweden AB (family company, owns 30%, technical and medical consulting). A. Farooqi has nothing to disclose. M. Domellöf has nothing to disclose. U. Ådén reports support for the present study from Region Stockholm and Karolinska Institutet, grants from Region Stockholm and Karolinska Institutet and the Childhood Foundation of the Swedish Order of Freemasons, and payment or honoraria for lectures, presentations, manuscript writing or educational events from Chiese Pharma (invited speaker at Nordic Neonatal Meeting 2021). C. Gadsbøll reports support for the present study and travel support from the Swedish Heart–Lung Foundation (20200808), Swedish Research Council (2020-01236), Swedish governmental funding of clinical research (ALF), and Region Skåne, Skåne University Hospital in Lund. K. Källén has nothing to disclose. D. Ley reports grants from ALF project grant, Lund University, and the Swedish Research Council. E. Normann has nothing to disclose. K. Sävman has nothing to disclose. A. Elfvin has nothing to disclose. S. Håkansson has nothing to disclose. M. Norman reports support for the present study from Region Stockholm and Karolinska Institutet, grants from Region Stockholm and Karolinska Institutet and the Childhood Foundation of the Swedish Order of Freemasons, royalties from Studentlitteratur AB, consultancy fees from Swedish Patient Insurance, payment or honoraria for lectures, presentations, manuscript writing or educational events from Chiese Pharma, and support for attending meetings from Chiese Pharma. R. Sindelar reports payment for expert testimony as External Auditor of Applications for Governmental Funding in paediatric, gynaecological/obstetrical, nephrological and urogenital diseases, Karolinska Institutet/Hospital Region Stockholm; and unpaid Chairman of the BPD Collaborative International Committee; and a leadership or fiduciary role as unpaid President for Neonatal Pulmonology, Swedish Neonatal Society, Swedish Paediatric Association; unpaid Board Member Neonatal Pulmonology, European Society of Paediatric Research; unpaid Member of the BPD Collaborative Executive Board, USA. F. Serenius reports support for the present manuscript from the Swedish Research Council (grant/award 2006-3858, 2009-4250). P. Um-Bergström has nothing to disclose., (Copyright ©The authors 2025.)

Objective: To evaluate if postnatal treatment with betamethasone in extremely preterm infants was associated with neurodevelopmental impairment (NDI) at 6.5 years of age., Design: Prospective cohort study., Setting: Extremely Preterm Infants in Sweden Study (gestational age <27 weeks, born 2004-2007)., Patients: 428 children born extremely preterm were assessed at 6.5 years of age, 115 treated with betamethasone and 313 not treated., Main Outcome Measures: NDI at 6.5 years of age. Evaluation at 6.5 years included cognitive testing with the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), neurological examination and a medical record review., Exposure: Treatment with postnatal betamethasone., Main Outcome: Moderate to severe NDI at 6.5 years of age, defined as a composite including cerebral palsy, and/or impairment in cognition, hearing and vision., Results: Moderate to severe NDI was more prevalent in children treated with postnatal betamethasone (49% treated vs 26% not treated, p<0.001). Betamethasone-treated children had worse cognitive development with mean WISC-IV score of 75 (SD 13.7) vs 87 (SD 14.0, p<0.001). The effect was dose dependent: 1.35 mg/kg vs 1.0 mg/kg (p=0.01) in betamethasone-treated children with moderate to severe versus no or mild NDI, respectively. The differences remained after adjustment for potential confounders with logistic regression (adjusted OR (aOR) 1.80, 95% CI 1.14 to 3.21). The difference in NDI also remained after propensity score matching, with crude OR 2.82 (95% CI 1.42 to 5.61, p=0.003) and aOR 2.17 (95% CI 1.07 to 4.69, p=0.04)., Conclusion: Postnatal treatment with betamethasone is associated with increased risk of NDI at 6.5 years., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ Group.)

Objective: To explore associations between perinatal activity and survival in infants born at 22 and 23 weeks of gestation in Sweden., Design/setting: Data on all births at 22 and 23 weeks' gestational age (GA) were prospectively collected in 2004-2007 (T1) or obtained from national registers in 2014-2016 (T2) and 2017-2019 (T3). Infants were assigned perinatal activity scores based on 3 key obstetric and 4 neonatal interventions., Main Outcome: One-year survival and survival without major neonatal morbidities (MNM): intraventricular haemorrhage grade 3-4, cystic periventricular leucomalacia, surgical necrotising enterocolitis, retinopathy of prematurity stage 3-5 or severe bronchopulmonary dysplasia. The association of GA-specific perinatal activity score and 1-year survival was also determined., Results: 977 infants (567 live births and 410 stillbirths) were included: 323 born in T1, 347 in T2 and 307 in T3. Among live-born infants, survival at 22 weeks was 5/49 (10%) in T1 and rose significantly to 29/74 (39%) in T2 and 31/80 (39%) in T3. Survival was not significantly different between epochs at 23 weeks (53%, 61% and 67%). Among survivors, the proportions without MNM in T1, T2 and T3 were 20%, 17% and 19% for 22 weeks and 17%, 25% and 25% for 23 weeks' infants (p>0.05 for all comparisons). Each 5-point increment in GA-specific perinatal activity score increased the odds for survival in first 12 hours of life (adjusted OR (aOR) 1.4; 95% CI 1.3 to 1.6) in addition to 1-year survival (aOR 1.2; 95% CI 1.1 to 1.3), and among live-born infants it was associated with increased survival without MNM (aOR 1.3; 95% CI 1.1 to 1.4)., Conclusion: Increased perinatal activity was associated with reduced mortality and increased chances of survival without MNM in infants born at 22 and 23 weeks of GA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate potential risk factors behind the increased incidence of necrotising enterocolitis (NEC) in Swedish extremely preterm infants., Design: Registry data from two population-based national cohorts were studied. NEC diagnoses (Bell stage ≥II) were validated against hospital records., Patients: All liveborn infants <27 weeks of gestation 2004-2007 (n=704) and 2014-2016 (n=895) in Sweden., Main Outcome Measures: NEC incidence., Results: The validation process resulted in a 28% reduction of NEC cases but still confirmed a higher NEC incidence in the later epoch compared with the earlier (73/895 (8.2%) vs 27/704 (3.8%), p=0.001), while the composite of NEC or death was lower (244/895 (27.3%) vs 229/704 (32.5%), p=0.022). In a multivariable Cox regression model, censored for mortality, there was no significant difference in early NEC (0-7 days of life) between epochs (HR=0.9 (95% CI 0.5 to 1.9), p=0.9), but being born in the later epoch remained an independent risk factor for late NEC (>7 days) (HR=2.7 (95% CI 1.5 to 5.0), p=0.001). In propensity score analysis, a significant epoch difference in NEC incidence (12% vs 2.8%, p<0.001) was observed only in the tertile of infants at highest risk of NEC, where the 28-day mortality was lower in the later epoch (35% vs 50%, p=0.001). More NEC cases were diagnosed with intramural gas in the later epoch (33/73 (45.2%) vs 6/26 (23.1%), p=0.047)., Conclusions: The increase in NEC incidence between epochs was limited to cases occurring after 7 days of life and was partly explained by increased survival in the most extremely preterm infants. Misclassification of NEC is common., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Aim: To determine the prevalence of neurobehavioral symptoms at 6.5 years in children born extremely preterm (EPT, <27 weeks' gestation)., Methods: Population-based cohort study of infants born EPT in Sweden from 2004 to 2007. Of 486 survivors 375 were assessed and compared with 369 matched term-born controls. EPT children free from neurosensory and intellectual disabilities (neurodevelopmental disabilities [NDD]-free, n = 236) were compared separately. Standardised questionnaires were used to assess parental ratings of hyperactivity and attention, emotional, peer-relation, conduct and social problems; and deficits in perception, language and memory., Results: EPT children had more reported problems in all assessed neurobehavioral domains than controls, with more than three times greater odds for most outcomes. Except for conduct problems, increased problems were identified also in NDD-free children. The odds of having neurobehavioral problems in ≥3 co-occurring domains were five (whole EPT group) and three (NDD-free group) times higher than in controls., Conclusion: EPT children with or without NDD have more neurobehavioral problems in multiple domains than term peers. Ongoing assessments of behaviour until school age or beyond should recognise early symptoms of attention, everyday social problems, perceptual, emotional or language difficulties., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Aim: Children born extremely preterm frequently have developmental coordination disorder (DCD). We aimed to evaluate perinatal risk factors for DCD., Methods: Swedish national cohort study including 226 children born before 27 gestational weeks without major neurodevelopmental disabilities at 6.5 years. Outcome was DCD, defined as ≤5th percentile on the Movement Assessment Battery for Children-Second Edition. Perinatal risk factors were evaluated using multivariable logistic regression., Results: DCD was present in 84/226 (37.2%) children. Of the risk factors known at 40 weeks gestation, independent and significant risk factors for DCD were: mother's age at delivery (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.07-2.80); pre-eclampsia (2.79, 1.14-6.80); mother born in a non-Nordic country (2.23, 1.00-4.99); gestational age per week increase (0.70, 0.50-0.99) and retinopathy of prematurity (2.48, 1.26-4.87). Of factors known at discharge, postnatal steroids exposure (2.24, 1.13-4.46) and mechanical ventilation (1.76, 1.06-2.09) were independent risk factors when added to the model in separate analyses., Conclusion: The risk of DCD in children born extremely preterm was multifactorial and associated with gestational age largely mediated by ROP, maternal factors, pre-eclampsia, administration of postnatal steroids and mechanical ventilation. These risk factors are common among children born extremely preterm, contributing to their high risk of DCD., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Aim: To investigate the predictive ability of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) Motor Index, in children born extremely preterm (<27 gestational weeks) without cerebral palsy., Methods: Children from the EXPRESS study (all extremely preterm births in Sweden, 2004-2007) without neurosensory impairments assessed with Bayley-III at 2.5 years corrected age and Movement Assessment Battery for Children, Second Edition (MABC-2), at 6.5 years comprised the eligible study population (n = 282). Motor difficulty was defined as MABC-2 ≤5th percentile., Results: Motor difficulties were found in 57 of 282 children (20.2%) at 6.5 years. The Bayley-III explained 18.0% of the variance in the MABC-2 (p < 0.001). The area under the receiver operating curve was 0.71 (95% confidence interval 0.64-0.79, p < 0.001). At a Bayley-III cut-off value of 85, sensitivity, specificity and positive and negative predictive values for motor difficulties were 26.3% (15.5-39.7), 92.9% (88.1-95.9), 48.4% (33.0-64.0) and 83.3% (80.9-85.4). Likelihood ratios were inconclusive., Conclusion: The Bayley-III at 2.5 years corrected age was a modest predictor of motor outcome in children born extremely preterm at 6.5 years, and underestimated the rate of motor difficulties. Children require follow-up beyond preschool age., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Aim: We investigated the timing of survival differences and effects on morbidity for foetuses alive at maternal admission to hospital delivered at 22 to 26 weeks' gestational age (GA)., Methods: Data from the EXPRESS (Sweden, 2004-07), EPICure-2 (England, 2006) and EPIPAGE-2 (France, 2011) cohorts were harmonised. Survival, stratified by GA, was analysed to 112 days using Kaplan-Meier analyses and Cox regression adjusted for population and pregnancy characteristics; neonatal morbidities, survival to discharge and follow-up and outcomes at 2-3 years of age were compared., Results: Among 769 EXPRESS, 2310 EPICure-2 and 1359 EPIPAGE-2 foetuses, 112-day survival was, respectively, 28.2%, 10.8% and 0.5% at 22-23 weeks' GA; 68.5%, 40.0% and 23.6% at 24 weeks; 80.5%, 64.8% and 56.9% at 25 weeks; and 86.6%, 77.1% and 74.4% at 26 weeks. Deaths were most marked in EPIPAGE-2 before 1 day at 22-23 and 24 weeks GA. At 25 weeks, survival varied before 28 days; differences at 26 weeks were minimal. Cox analyses were consistent with the Kaplan-Meier analyses. Variations in morbidities were not clearly associated with survival., Conclusion: Differences in survival and morbidity outcomes for extremely preterm births are evident despite adjustment for background characteristics. No clear relationship was identified between early mortality and later patterns of morbidity., (© 2021 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)